"SIMSBURY PUBLIC SCHOOLS"
SIMSBURY PUBLIC SCHOOLS NOTICE OF PRIVACY PRACTICES Pursuant to the Privacy Regulations resulting from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCCES TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. The Simsbury Public Schools - Employee Benefit Health Care Plan (the "Plan") is required by law to put in place reasonable measures that protect the privacy of your individually identifiable health information that is transmitted or maintained by the Plan in any form. This health information is considered protected health information ("PHI"). The Plan also must give you this notice of its legal duties and privacy practices related to your PHI. It is required to abide by the terms of this notice as currently in effect. There are other laws that give you additional protections for PHI related to mental health and HIV/AIDS treatment and treatment of alcohol and other substance abuse. The Plan will comply with those laws if they apply to your PHI. Privacy Pledge Simsbury Public Schools does not disclose your nonpublic personal medical and financial information, except as required or permitted by law. Simsbury Public Schools will ensure that its' practices and standards comply with HIPAA and other applicable federal and state laws and regulations. Simsbury Public Schools will work with appropriate regulatory and accreditation agencies to ensure consistency between our policies and HIPAA. Simsbury Public Schools will uphold the higher privacy standard when there is a conflict between applicable state and federal regulations. Sources of Information Received Simsbury Public Schools receives nonpublic personal medical and financial information about employees from the following sources: 1. Applications, consents, authorizations and other forms you or your representatives provide; 2. Documentation collected while under a physician's care (test results, physician notes, etc.); 3. Billing and payment transactions with us, our affiliates and others (such as health claim submissions with insurance companies); 4. Outside sources pertaining to your care or coverage such as health care providers, insurance companies and federal and state agencies. Protection of Information Simsbury Public Schools policies restrict access of your information to employees who need this information to provide services to you and as permitted by law. We maintain physical, electronic and procedural safeguards that comply with legal requirements to protect your nonpublic personal medical and financial information. Simsbury Public Schools HIPPA - Notice of Privacy Practice A. Obligations of the Plan to use and/or disclose Protected Health Information (PHI) The Plan is required to use and/or disclose your PHI: 1. To you when you exercise your right of access and/or right to an accounting; 2. To the Secretary of the U.S. Department of Health and Human Services for an investigation and/or a determination of the Plan's compliance with federal privacy law. B. Rights of the Plan to use and/or disclose Protected Health Information (PHI) without your authorization The Plan has the right to use and/or disclose your PHI: 1. Treatment - to provide you with treatment and to coordinate or manage your health care. (For example - the Plan may disclose to your oral surgeon the name of your dentist so they are able to confer about your care and share information to treat you.) 2. Payment - for any reason related to payment for your medical treatment and/or services including but not limited to, making determinations of eligibility or coverage and to certain other persons or companies that perform services, related to payment, for the Plan. (For example - the Plan may inform a physician of your eligibility for medical coverage.) 3. Health Care Operations – to support the Plan’s operations and to certain other persons or companies that perform services, related to the Plan’s health care operations. (For example – it may use your PHI to conduct quality assessment and improvement activities, to secure or place a contract for reinsurance of risk relating to health care claims, or to refer you to a disease management program.) C. Other Circumstances when the Plan may use and/or disclose protected health information without your authorization The Plan may use and/or disclose your PHI: 1. As Required by Law – when required to do so by federal, state or local law. 2. Public Health Risks – for public health activities. Your PHI can be disclosed to public health officials for use: a. To prevent or control disease, injury or disability; b. To report births and deaths; c. To report child abuse or neglect; d. To collect or report reactions to medications or problems with products; e. To track Food and Drug Administration-regulated products; f. To enable product recalls, repairs, replacement or lookback, including notifying people of recalls of products; g. To conduct post-marketing surveillance; h. To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. 3. Reporting Victims of Abuse, Neglect or Domestic Violence – to notify a government authority if the Plan reasonably believes you are a victim of abuse, neglect or domestic violence. The Plan may disclose your PHI to the extent the disclosure is required by law or to the extent you agree to the disclosure. 4. Health Oversight Activities – to a health oversight agency for activities authorized by law, including audits, investigations, inspections and licensure. 5. Judicial and Administrative Proceedings – in response to a court or administrative order. The Plan may also disclose your PHI in response to a subpoena, discovery request or other lawful process, by only if reasonable efforts have been made to inform you about the request or to secure a qualified protective order. HIPAA Plan Document 2 of 5 Compliance Date: April 14, 2004 Simsbury Public Schools HIPPA - Notice of Privacy Practice 6. Law Enforcement – for certain law enforcement purposes, including the following: a. To comply with a court order, subpoena, warrant, summons or similar process; b. To identify or locate a suspect, fugitive, material witness or missing person; c. To comply with requests for information pertaining to the victim of a crime if, under certain limited circumstances, the Plan is unable to obtain your assent; d. To comply with reporting requirements ore report emergencies or suspicious deaths; e. To report crimes that occurred on the premises; f. In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. 7. Coroners, Medical Examiners and Funeral Directors – to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties authorized by law. The Plan may also disclose your PHI to funeral directors as necessary to carry out their duties. 8. Organ and Tissue Donation – to organ procurement organization or other organizations involved in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant. 9. Research – under certain circumstances for research purposes. Your PHI will only be used and/or disclosed: if the privacy aspects of the research have been reviewed and approved by a special privacy board or institutional review board; if the researcher collects your PHI to prepare for a research proposal; if the research occurs after your death; or if you authorize the use and/or disclosure of your PHI. 10. To avert a serious threat to health or safety – when necessary to prevent a serious threat to the health and safety of the public or another person. Any disclosure, however, would only be to the person reasonably able to prevent or lessen the threat. 11. Armed Forces – If you are a member of the armed forces, as required by military command authorities. The Plan may also disclose PHI about foreign military personnel to the appropriate foreign military authority. 12. National Security and Intelligence Activities – to authorized federal officials for the conduct of lawful intelligence, counterintelligence and other national security activities authorized by law. 13. Protective Services for the President and Others – to authorized federal officials for the provision of protective services to the President, other authorized persons or foreign heads of state or for the conduct of authorized investigations. 14. Workers’ Compensation – to comply with workers’ compensation laws and other similar legally established programs that provide benefits for work-related injuries or illnesses without regard to fault. 15. Limited Data Set – for purposes set forth in a valid data use agreement with the limited data set recipient, but only PHI that excludes certain direct identifiers, such as name and telephone numbers. 16. Plan Sponsor – to the sponsor of the Plan for purposes related to the plan administration if the Plan sponsor has amended its plan documents to protect your PHI as required by federal law. 17. Individuals involved in your care or payment for your care – to a friend, family member or other person identified by you who is involved in your medical care unless you notify the plan that you object to or want to restrict disclosure. The Plan may also disclose your PHI to a friend, family member or other person identified by you who assists in the payment of your medical care. It may also inform a family member, a personal representative or another person responsible for your care of your condition and/or your location. HIPAA Plan Document 3 of 5 Compliance Date: April 14, 2004 Simsbury Public Schools HIPPA - Notice of Privacy Practice 18. Incident to a Use and/or Disclosure Otherwise Permitted or Required – incidentally during a permitted or required use or disclosure. Other used and/or disclosure of your PHI will be made only with your written authorization. With certain limited exceptions, the Plan must obtain an authorization for any use and/or disclosure of psychotherapy notes or for any use and/or disclosure of PHI for marketing purposes. Generally, you have the right to revoke any written authorization. D. Your Rights Regarding Your Protected Health Information 1. Right of Access – With certain limited exceptions, you have the right to inspect and copy your PHI contained in a “designated record set” that the Plan maintains. A designated record set is a group of records that include PHI and are maintained, collected, used or distributed by or for the Plan that: contains medical records and billing records about individuals; contains enrolment, payment, claims adjudication, and case or medical management record systems; or is used to make decisions about individuals. The Plan may give you a summary of the PHI you requested instead of providing access to the PHI, or the Plan may give you an explanation of the PHI that it provides to you, if you agree to the summary or explanation and to any fees to be imposed for the summary or explanation. You must agree, orally or in writing, to these fees before the Plan can charge them to you. The Plan may charge a reasonable cost-based fee for the cost of copying, mailing, or other supplies associated with your request. In certain instances, the Plan may deny your request to inspect and copy your PHI. If you are denied access, in some cases you may request that the denial be reviewed. In those cases, the Plan will designate a licensed health care professional (the “reviewer”) to review your request and the denial. The reviewer will not be the same person who denied your first request. The Plan will take all actions necessary to carry out the reviewer’s determination. 2. Right to Amend – You have the right to have the Plan amend your PHI for as long as the Plan maintains that information. Also, you must provide a reason that supports your request. The Plan may deny your request for an amendment if it is not in writing or does not include a reason that supports the request. In addition, the Plan may deny your request if you ask the Plan to amend information that: was not created by the Plan, unless the originator is no longer available to act on the requested amendment; is not part of the PHI kept by the Plan; is not part of the PHI which you would be permitted to inspect and copy; or already is accurate and complete. 3. Right to an Accounting or Disclosures – You have the right to receive an accounting of the Plan’s disclosures of your PHI for the past six years. However, the listing of disclosures will not include disclosures made to carry out treatment, payment and/or health care operations, or with your authorization, or to you, or prior to April 14, 2004. The first accounting the Plan gives to you within a 12-month period will be free. For each subsequent request for an accounting during that 12-month period, the Plan may impose a reasonable cost-based fee. The will notify you of the cost involved and you may choose to withdraw or modify your request before you incur any costs. 4. Right to Request Restrictions – You have the right to instruct us not to disclose your PHI to someone who is involved in your medical care or the payment for your medical care. In addition, you have the right to request a restriction on the uses and /or disclosure of your PHI for treatment, payment and/or health care operations. The Plan is not required to agree to a restriction that you request. If the Plan does agree, it will comply with your request unless the PHI is needed for your treatment in an emergency. 5. Right to Request Confidential Communications – You have the right to request that you receive communications of your PHI from the Plan by alternative means or at alternative locations. Your request must contain a statement that disclosure of all or part of the information, by typical means or to your regular address, could endanger you. The Plan will accommodate all reasonable requests that provide sufficient evidence of endangerment. Your request must contain information regarding an alternative address or other method of contact. HIPAA Plan Document 4 of 5 Compliance Date: April 14, 2004 Simsbury Public Schools HIPPA - Notice of Privacy Practice 6. Right to a Paper Copy of this Notice – You have the right to a paper copy of this notice. You may ask the Plan to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. E. Complaints If you believe your privacy rights have been violated, you may file a complaint with the Plan or with the Secretary of the U.S. Department of Health and Human Services (“DHHS”). To file a complaint with the DHHS, mail your complaint to Office for Civil Rights, U.S. Department of Health and Human Services, JFK Federal Building, Room 1875, Boston, MA 02203. You must submit all complaints in writing. The Plan will not retaliate against you for filing a complaint. The Plan reserves the right to change its privacy practices and to change the terms of this notice to reflect those changed practices. The Plan reserves the right to make the new notice provisions effective for all PHI that the Plan maintains. The Plan will make a copy of the most recent notice available upon request. If the Plan makes a material change to the permitted or requested uses and/or disclosures of your PHI, or your rights explained in this notice, or the Plan's legal duties or other privacy stated in this notice, the Plan will distribute a revised notice within sixty (60) days of that type of change. Privacy Official Contact Information: Teresa Heintz Simsbury Public Schools Employee Benefits/Wellness Coordinator 933 Hopmeadow St. Simsbury, CT 06070 Tel. 860-651-3361 Fax 860-651-4343 e-mail – email@example.com HIPAA Plan Document 5 of 5 Compliance Date: April 14, 2004